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Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.

Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.

High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.

Children undergoing intrahospital transport are at risk for adverse events. This study used perioperative adverse event data reported to a patient safety organization to identify pediatric anesthesia transport-associated adverse events. A small proportion (5%) of pediatric anesthesia adverse events were associated with transport, but the majority of events were deemed preventable and one-third resulted in patient harm. Cardiac arrest and respiratory events occurred most frequently and largely affected very young children (<6 month). A previous WebM&M discussed a perioperative respiratory event in a pediatric patient during intrahospital transport.

Researchers analyzed medication errors occurring in the trauma service of a single university hospital in Spain to inform the development and implementation of a set of measures to improve the safety of the pharmacotherapeutic process. The Multidisciplinary Hospital Safety Group proposed improvement measures that intend to involve pharmacists in medication reconciliation, increase the use of medication reconciliation in the emergency and trauma departments, and incorporate protocols and alerts into the electronic prescribing system.

This study explored the impact of longitudinal medication reconciliation performed at transitions (admission, discharge, five-days post-discharge). Medication changes implemented due to longitudinal reconciliation prevented harm in 82% of patients. Potentially serious errors were frequently identified at hospital discharge and commonly involved antithrombotic medications.

This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).

This systematic review of 54 studies found that over half of adult and pediatric patients experienced a medication error post-discharge, and that these errors regularly involved common drug classes such as antibiotics, antidiabetics, analgesics, and cardiovascular drugs. The authors suggest that future research examine the burden of post-discharge medication errors, particularly in pediatric populations.

Pharmacists are critical to ensuring safe transitions between acute care and skilled nursing facilities (SNFs). This retrospective study evaluated the frequency of missed doses of high-risk medications after hospital-to-SNF transfers and found that 60% of first doses of high-risk medications were given after the scheduled administration time. After implementation of a medication order process including pharmacist-led medication reconciliation, the average delay in medication administration decreased significantly. 

This systematic review synthesizes the evidence from 14 studies on medication reconciliation in cancer patients. While the majority of studies did not include a contemporaneous comparison group, they did report that medication reconciliation led to medication error identification (most frequently drug omissions, additions or dosage errors) in up to 88-95% of patients.

Effective teamwork is critical to ensuring patient safety, particularly in intensive settings such as critical care. This paper describes a “hackathon” – an intensive problem-solving event commonly used in computer science designed to stimulate creative solutions – focused on the challenges encountered by rapid team formation in critical care settings (such as for cardiac resuscitation). Hackathon teams were multidisciplinary, comprised of healthcare professionals and academics with expertise in communications, psychology and organizational sciences. The paper briefly discusses the three solutions proposed, and the impacts of leveraging this approach for solving other problems specific to health care management.

Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.  

Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.

Pharmacists are expanding their reach as stewards of medication safety into the front line of care. This project report describes the pilot testing of pharmacist involvement in development and review of medication orders in the discharge workflow. A substantive percentage of medication problems were prevented due to pharmacist engagement.